PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Things have been in disarray at the PookieMD household–Hubby got laid off two days ago, and we are picking up the pieces.  As a wife of an engineer that loves working in small companies, you would think I would be used to this.  But I’m not.  I am trying to get better at it, looking at it constructively, asking what I can learn from it.

But it is still a really scary place to be.

I go through the seven stages of grief every time.  Warning–rest of post may be a bit whiney for those hard-core-stiff-upper-lip people!

Shock: yesterday I was shocked, but I think this wore off quickly as I have been worried that Hubby would be the next under the axe as 3 of the 15 people company had already received their walking papers.

Denial: Hubby is at this stage–”well what if I get a job next week?”, he asked.  What if, indeed!

Anger: for me, it is the turning upside down of my carefully crafted world, the helplessness I feel at not being able to control everything that is enraging.  It is tempting to blame someone, but I know there is no one to blame.  I spent a lot of time sitting on my front step the last two days so I wouldn’t yell at Hubby.  Helplessness makes me furious!

Bargaining: nah, I don’t bother with this stage.  What’s there to bargain about and who to bargain with?

Depression: not there yet.  I think this will depend on the length of the lay off.  We are bracing for at least 6 months, if not longer, given the economy.

Testing: I have already taken more shifts at the hospital, and Hubby has already found a some jobs to apply for.   I have always worked 2/3rds time as a hospitalist so I can spend more time with my daughter, but I will have to give up that for a while.  I know I am lucky I have this option, but I am also sad, because spending time with my daughter when she is out of school is one of the greatest joys of my life.  In addition, we went through our budget via an excel spread sheet, and know we can go a year on my salary as a physician and president of ExtraMD.

Acceptance: does any one ever accept bad news?  I don’t know if I will ever get to this stage–maybe more study of Eastern Religions would help.

All right, enough whining and tissue wringing!  If anyone needs an electrical engineer let me know, and if you want me to cover some shifts, I’m here for you!

There is a blog similar to this one, called Making It, written by Douglas Iliff, MD, a family practitioner. He blogs on the American Family Physician website. Here is what he says about patients and non-payment of debt:

“I have only tossed a couple of patients out of my practice face-to-face. One of them was a pretty good friend who kept verbally abusing my staff. I’ve never done it for non-payment of debt. But lots have been booted out by a process that I consider both just and merciful…The key is that I make it clear that no one will ever be dumped for inability to pay. If they ask for their debt to be forgiven, it will probably be forgiven. If they want to pay $5 per month, that will be fine. Here’s the key paragraph from the letter patients get before they are turned over to collections:

“I’ve tried to be human about debts. Anybody who tries to make arrangements to pay, and then follows through without our badgering, will make us happy. I don’t care if your monthly payment will never retire the debt. Just don’t make us keep sending you bills. That’s all we ask.” ”

I have one issue with Dr. Iliff’s post: how do you keep the doors open if your revenues are not greater than expenses, no matter how noble your intentions are? Remember PookieMD’s number one rule of practice: you can’t see patients if you can’t keep the doors open.
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Photo: sonofthesouth.net

I have a very simple way to save the government billions of dollars in health care costs, and make Americans healthier, almost immediately:

Outlaw tobacco.

Likely to happen? Not a chance.  The tobacco lobby is way too powerful, and the tobacco states will rally loudly and strongly against it, not to mention big pharma that will see a decrease in revenues as the use of patches, gums and pills goes down.

Okay, next option: tax the poo out of cigarettes.  Currently the average tax by state on a package of cigarettes is $1.19.  The state with the lowest?  Not surprising, South Carolina, where the tax is just $0.07.  The tobacco states  average is $0.33 per pack, while other states average is $1.30.  Pathetic, but it shows that there is a lot of room to increase the taxes, especially in the tobacco states.  There should be a HUGE federal tax on cigarettes.  Likely to happen?  See above r.e. tobacco lobby.

Next option: teach ‘em young.  The feds need to mandate a  ’smoking is bad’ curriculum YEARLY kindergarten through 12th grade.

Last option: We docs keep plugging at our patients.  I’m not so optimistic on this accord, but I’ll keep trying.  Here was my must recent attempt to convince a patient to stop smoking.  I report a conversation I had with a 70ish year old gentleman, on his way to the OR to have his foot whacked off secondary to peripheral vascular disease.

Me:  (earnestly) Mr. Marlboro, what can I do to help you stop smoking? Would it be helpful to have the nicotine patch while you are in the hospital?

Mr. Marlboro: (just as earnestly)  No, I don’t need the patch.

Me: You know, while you are in the hospital, it’s a great time to quit, because you can’t smoke here.  Besides, cigarettes are so expensive.

Mr. Marlboro: Well, I don’t care about the expense.  I’d just spend the money on something else.  Besides, I’ve smoked all my life, and it’s never hurt me.

At this moment, the transport team arrives to take him to the operating room.

Me: (defeated) Oh.

Good luck out there.  Sounds like I need to brush up on my motivational stop smoking speech, as I’m not envisioning President Obama or Mr. Daschle following my suggestions.

See the December 29 post and enter your practice’s goals for 2009.  Include a plan by which your will achieve the goals.  The best plan wins a $15 gift card from Amazon.

One of my favorite rants is “What we didn’t learn…”  I remember finishing my residency in internal medicine, thinking I had learned everything I needed to go out and cure patients, save the world, and get paid while doing it.  Boy was I wrong.  It was just the beginning!  Some of the lessons have come harder than others: I have had to learn that medicine is really a business, and that no matter how hard you try you can’t know everything.  So I thought I would come up with a manifesto on what we REALLY need to know.  So with out further ado:

1) Medicine is a business.  Get used to it.  Know that if you can’t keep the doors open, you can’t see patients.

2) Insurers run the world.  Get used to it.  Know which insurers reimburse the least and lose ‘em if you can.

3) Learn all you can about coding and billing.  You deserve to paid for the work you do.  Most physicians undercode.  (Yes, I remember the 3 minute lesson I received as a senior resident:  “if the patient is complicated, code higher.”  Not exactly what I needed to know!)

4) Constantly look for ways to be effective and efficient.  Go through your day, minute by minute, and see what you can do differently.  Just try it.

5) Computers and EMRS are your friends.  Embrace technology because it is here to stay.  Get used to it.

6) Decide what is important to you, THEN pick what you want to do.  If you want shift work, think urgent care or hospital medicine.  If you want autonomy, consider a micropractice, if you want a guarantee think large practice or HMO.   Learn as  much as you can about each practice.  Remember, if you don’t like something, you can always change it!

7) Surround yourself with good people.  Have a good bookkeeper, accountant and attorney.  The flip side is, never blindly surrender your business/practice to someone else.  Understand financial statements, cash flow and personnel issues.  Don’t become one of those sad physicians that tells you their bookkeeper/accountant/office manager/partner/medical assistant ran off with receivables.  Ignorance is not a good strategy.
 Constantly learn.  Look for ways to learn from patients, staff and the slow lady yapping on her cell phone in the “fast” lane.  Some patients are there to teach you patience, and sometimes the slow lady reminds you to go the speed limit!

9) Remember two rules of medicine  (Thanks to M*A*S*H!)  First, patients die.  Second, doctors can’t change rule number one.

10) Breathe.  It’s tough to be a doctor in the trenches today, with the health care mess, Wall Street madness and the litiginous climate.  However, you ARE doing good!

May at least one person thank you today, to remind you that being a physician IS a worthwhile profession!

Economic times will absolutely mean  big things for the business of medicine.  The amount of insured patients will go down, and the number of uninsured patients will go up.  So what does that mean to us, the primary care docs in the trenches? How do we shore up our economic coast and continue to see patients, which is what we trained for?  The obvious answer is first, to be prepared.  Decide in advance how much “self pay” your practice can afford and have a way patients can set up a payment plan.  Collect copays when they are due, and be prepared to challenge insurance companies to get paid for the work you do.

The bigger questions is: what can we do about health care in the United States? What solutions do YOU have as to providing care for the uninsured/underinsured?  Are your ready to become a leader?  What education do ALL physicians need to ensure we can deliver the care we all want to give?

I encourage all of you to get active in the political and economic climate we are in!  Stand up and make you voice heard!  We as physicians are uniquely qualified to guide our country in supplying appropriate care to our fellow citizens.